Let’s Get Back On The Road To Care

At Accelerate The Care, we are driving change, one caregiver at a time.

Caregiver Automobile Assistance Program - Application Form

Thank you for your interest in our Caregiver Automobile Assistance Program. This program provides $500 in assistance to caregivers of individuals with Alzheimer's or dementia who need help with automobile-related expenses. Please complete all sections of this application. Applications are reviewed as quickly as possible. please feel free to reach out to Acceleratethecare@gmail.com if you have not heard from us within 48 hours of submission.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Best time/method to contact you?

Name of person with Alzheimer's/dementia or Facility

Your relationship to this person (ignore if facility)

How long have you been providing care?

Do you live with the person you care for?

Yes

Approximate hours per week spent caregiving

Please Tell us The Make, Model and Year of the vehicle that needs repairs

Please describe the specific automobile need and how it impacts your caregiving responsibilities (100-150 words)

If your car is currently in a repair shop: Name of repair shop/mechanic/Phone Number

Estimated cost of repairs needed

Number of people in household

Are you currently receiving any of the following? (check all that apply)

None

Medicaid

SNAP/Food Stamps

SSI/SSDI

Other assistance programs

Please briefly explain your financial situation and why this assistance would be helpful (50-100 words)

How would receiving this assistance impact your ability to provide care? (100-150 words)

Please provide one reference who can verify your caregiving situation (healthcare provider, social worker, support group leader, etc.)

Provide name, relationship, phone number, and email.

How did you hear about us?

I certify that all information provided in this application is true and complete to the best of my knowledge. I understand that Accelerate the Care may verify any information provided. I authorize the release of information necessary to process this application.

Signature

Date

Let’s Get Back On The Road To Care

Caregiver Automobile Assistance Program - Application Form

For questions please contact Acceleratethecare@gmail.com